Nicola Cassanelli

Typical and atypical pulmonary carcinoids: our institutional experience

Pulmonary carcinoids are rare malignant neoplasms, accounting for 2-5% of all lung tumors, with an approximate annual incidence of 2.3-2.8 cases per million of the population. We relate our experience of 54 patients (21 male, 33 female, mean age 53+/-15 years) treated between July 1986 and April 2006. All the patients underwent preoperative fibrobronchoscopy: preoperative diagnosis was made in 28 patients (52%). Surgical treatment consisted of: 31 standard lobectomies, 6 pneumonectomies, 5 bilobectomies, 2 sleeve lobectomies, 2 anatomic segmentectomies, 6 wedge resections; two patients were managed with sleeve bronchial procedure of the left main bronchus without lung resection. Fifty-four patients were followed with a mean time of observation of 67 months: 6 (11%) deaths occurred, at a mean period of 49 months after surgery; there were no postoperative deaths. Overall, 5-year survival was 91%, 10 years 83%: 5-year survival was 91% for typical carcoinoids (TC) vs. 88% for atypical (AC), 10 years 91% for TC and 44% for AC (significant value, P=0.0487). Carcinoid tumors are a distinct group of neuroendocrine tumors with a good prognosis in most cases. Surgery currently represents the best treatment with good results at mid- and long-term survival, according to an acceptable risk.

An alternative technique for anterior chest wall reconstruction: the sternal allograft transplantation.

OBJECTIVES Sternal resection is indicated for a variety of pathological conditions, mainly neoplastic or related to sternotomy complications. Resection of the sternum generally leaves a large chest-wall defect, and reconstruction is thus the most difficult part of the operation. Correct stabilization of the anterior chest wall is very important to avoid secondary complications and respiratory failure. In the last few years, different technical solutions have been used to reconstruct the sternum. We describe our technique using a sternal allograft to reconstruct the anterior chest wall after partial or complete sternal resection. METHODS Between June 2010 and February 2012, four patients underwent sternectomy followed by anterior chest wall reconstruction using sternal allograft. The sternal allograft was harvested from a multitissue donor following Italian legislation for tissue donation. Three patients had neoplastic involvement of the sternum, and one had a complete sternal defect as a complication of a cardiac operation. RESULTS We had no operative mortality. Three patients underwent partial sternal transplantation, and one underwent total sternal replacement. We had no postoperative respiratory insufficiency, infections or mechanical failure of the reconstructions. The respiratory function was preserved in all patients. The follow-up period was free from complications related to the sternal allograft implantation. CONCLUSIONS The technique of sternal allograft transplantation is simple, reproducible and provides excellent functional and cosmetic results. Further studies including a larger number of patients are needed to understand the biology of the allograft and the long-term results of this technique.

Can Topical Application of Tranexamic Acid Reduce Blood Loss in Thoracic Surgery? A Prospective Randomised Double Blind Investigation

OBJECTIVE The systemic or topical use of antifibrinolytic agents is effective in reducing postoperative bleeding and blood product transfusion in cardiac surgery. We sought to study the effect of the topical application of tranexamic acid into the pleural space to reduce postoperative bleeding after lung surgery. METHODS This was a prospective randomised double blind placebo controlled investigation. From May-2010 to February-2012, 89-patients, scheduled for pulmonary resection, were randomly allocated to one of the two study groups. Group-A received 5 g of tranexamic-acid in 100 ml of saline solution. Group-B received 100 ml of saline solution as placebo. RESULTS The blood loss in the first 12-h was significantly less in group-A. The same trend was observed in the first 24-h but without reaching a true statistical significance. The mean volume of blood transfusion was statistically lower in group-A. The analysis between post-operative haemoglobin concentration, haematocrit, platelet-count, international-normalised-ratio, fibrinogen and partial-thromboplastin-time of both groups was not statistically significant. CONCLUSION In our experience, the topical use of tranexamic-acid after lung surgery reduces postoperative bleeding and blood transfusion volume. The topical administration of tranexamic-acid is safe without increasing the risk of post-operative complications related to pharmacological side-effects.

Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma.

Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.

Surgical results and long-term follow-up of T4-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins

Patients with locally advanced non-small cell lung cancer infiltrating the left atrium (LA) or the intrapericardial base of the pulmonary veins (PVs) are generally not considered good candidates for surgery because of the poor long-term survival. In the last 10 years, 31 consecutive patients with non-small cell lung cancer directly invading the LA or the intrapericardial base of the PVs underwent surgery. Pneumonectomy was the operation performed most frequently. In-hospital mortality was 9.7% and overall morbidity was 52%. One-, 2- and 3-year survival rates were 64, 46 and 30%, respectively with a mean survival of 22 months. The systemic recurrence of disease was the major cause of death at follow-up. At statistical analyses, the N-factor and the type of operation were related to poor long-term survival. In these patients, surgery could be performed with an acceptable operative mortality and morbidity. Surgery should be considered whenever a complete resection is technically possible. A careful preoperative evaluation is mandatory to select good candidates for surgery.

Accuracy of transthoracic ultrasound for the prediction of chest wall infiltration by lung cancer and of lung infiltration by chest wall tumours.

BACKGROUND We wanted to determine the accuracy of transthoracic ultrasound in the prediction of chest wall infiltration by lung cancer or lung infiltration by chest wall tumours. METHODS Patients having preoperative CT-scan suspect for lung/chest wall infiltration were prospectively enrolled. Inclusion criteria for lung cancer were: obliteration of extrapleural fat, obtuse angle between tumour and chest wall, associated pleural thickening. The criteria for chest wall tumours were: rib destruction and intercostal muscles infiltration with extrapleural fat obliteration and intrathoracic extension. Lung cancer patients with evident chest wall infiltration were excluded. Transthoracic ultrasound was preoperatively performed. Predictions were checked during surgical intervention. RESULTS Twenty-three patients were preoperatively examined. Sensitivity, specificity, positive and negative predictive values of transthoracic ultrasound were 88.89%, 100%, 100% and 93.3%, respectively. Youden index was used to determine the best cut-off for tumour size in predicting lung/chest wall infiltration: 4.5cm. At univariate logistic regression, tumour size (<4.5 vs ≥ 4.5cm) (p=0.0072) was significantly associated with infiltration. CONCLUSIONS Transthoracic ultrasound is a useful instrument for predicting neoplastic lung or chest wall infiltration in cases of suspect CT-scans and could be used as part of the preoperative workup to assess tumour staging and to plan the best surgical approach.

Sternal Resection and Reconstruction for Local Recurrence of Breast Cancer Using the Sternal Allograft Transplantation Technique

Sternal involvement in patients with breast cancer is relatively rare and its treatment is still controversial. Surgery is usually indicated in cases of single metastases in a multimodality protocol. Partial or complete sternectomy associated or not with the resection of surrounding tissues is the technique of choice to obtain safety margins and radical treatment of the disease. The most challenging part of the operation is the reconstruction of the anterior chest wall in order to avoid secondary complications and respiratory failure. In the last few years, different techniques and materials have been used to reconstruct the sternum. We report our experience in two patients with recurrent breast cancer using the sternal allograft technique to replace the sternum after partial sternectomy. The use of a sternal-allograft provides excellent functional and cosmetic results without complications during the follow-up period. The implantation technique is simple and reproducible.

A Massive Post-Sternotomy Sternal Defect Treated by Allograft Sternal Transplantation

Abstract  We report a case of a patient with complete sternal destruction after cardiac surgery, who underwent total sternal replacement with sternal allograft, titanium bars, and screws. (J Card Surg 2012;27:557‐559)

Right Pneumonectomy for T4 Non-small Cell Lung Cancer Invading Intrapericardial Pulmonary Vein in a Patient with a Right Aortic Arch

A 59 year-old man with a right-sided aortic arch who had a T4 right lung cancer invading the proximal superior pulmonary vein underwent an intrapericardial-pneumonectomy with partial left atrium resection and a radical lymphadenectomy. The presence of a right-sided aortic arch required particular attention during dissection of the lymph nodes. This is the first case of a right-pneumonectomy for T4-lung cancer in a patient with a right-sided aortic arch.

Desmoid Tumour of the Thoracic Outlet in a 70 Year-old Man Successfully Removed Through Cervico-thoracic Dartevelle Approach

Desmoid tumours have a strong tendency for local invasion and recurrence. A 70 year-old male presented with cervical and left shoulder pain associated with a supraclavicular mass. The computed-tomography showed an expansive lesion measuring 10 cm × 6 cm × 5.5 cm in the left supraclavicular space. At magnetic resonance imaging the subclavian vessels and the brachial plexus were dislocated anteriorly but not infiltrated. An incisional biopsy suggested a desmoid tumour. An anterior cervicothoracic approach was used to remove the tumour. The chest wall was reconstructed with titanium bars and a polytetrafluoroethylene-patch. The clavicle was fixed using a titanium clip. The post-operative course was uneventful. The patient was treated with adjuvant radiation therapy. After six months the patient is in good clinical condition free from disease recurrence. In conclusion, desmoid tumour of the thoracic outlet is a challenging situation. Wide radical resection should be attempted whenever possible. The Dartevelle approach gives an optimal surgical field with direct control of vessels and nerve roots facilitating tumour dissection and radical resection en-bloc with the chest wall. The chest wall reconstruction with titanium bars and clips is a simple and effective method to guarantee good respiratory function and to stabilise the shoulder girdle.